NON ALCOHOLIC STEATO HEPATITIS (NASH)

Introduction

In some individuals there is an abnormal deposition of fat in the liver causing it to swell and enlarge. While regular alcohol consumption can bring this about in some, it may be due to other (non-alcoholic) causes in many. The spectrum of this abnormal deposition of fat in the liver (Non-Alcoholic Fatty Liver Disease or NAFLD) can rangefrom mild deposition of fat in liver (termed as steatosis in medical terminology) to active severe liver cell injury (called steatohepatitis). The importance of NASH is due to the observation that it can progress over years to liver cirrhosis and liver failure(end-stage liver disease where liver structure and function are altered to an irremediable state and liver just gradually stops working appropriately) in some patients. Hence early recognition and steps to halt and reverse the process is advisable.

What is NASH?

Non-alcoholic steatohepatitis (NASH), also known as fatty liver hepatitis, is a clinical-pathological condition that only recently has been recognized to be a common and potentially severe form of liver disease. NASH is usually defined on the basis of liver biopsy histology, characterized by accumulation of fat in hepatocytes, spotty necrosis, inflammation, Mallory bodies and fibrosis. These features resemble alcoholic liver disease, but this condition occurs in persons who drink little or no alcohol. NASH appears to be common, although its prevalence in the population is not well defined. Selected autopsy series have found fatty hepatitis in 3% of lean and up to 19% of obese subjects. NASH is most common in middle-aged persons but is found in all age groups including children. It typically occurs in persons who are overweight or diabetic, but it has recently been shown to occur in subjects with normal body weight and normal glucose tolerance. In some series, NASH has been found to be the single most common cause of serum aminotransferase abnormalities identified during routine blood testing.

What is the difference between NAFLD and NASH?

NASH is part of a group of liver diseases, known as non-alcoholic fatty liver disease or NAFLD, in which fat builds up in the liver and sometimes causes liver damage that gets worse over time (progressive liver damage). Thus it is this spectrum of abnormal deposition of fat in the liver (NAFLD) which includes and can range from plain deposition of fat in liver (termed as steatosis in medical terminology) to active severe liver cell injury (called steatohepatitis) accompanying it. Bland steatosis is rarely harmful and so it is the group comprised by NASH which concerns us more, as patients with NASH can progress to end stage liver disease. Early on, the build-up of fat does not affect the function of the liver, and you will have no symptoms. As fat continues to build up and inflammation occurs, liver function begins to decline and symptoms develop. This inflammation may lead to scarring and severe damage of the liver which leads to cirrhosis. Cirrhosis means that the liver has become scarred and hardened and is not able to work normally. There is no clear reason why some people with fatty liver develop NASH and others do not.

What are the causes of NASH?

The cause of NASH is not yet defined. Its association with obesity and diabetes suggests an underlying metabolic dysfunction, perhaps insulin resistance or inability to metabolize excess free fatty acids. However, accumulating evidence indicates that there is a second factor that ultimately leads to cell injury and inflammation in fatty liver. The suspected second 'hit' may be intracellular oxidative stress that can be induced by multiple mechanisms, such as excess iron accumulation, endotoxin exposure, pro-inflammatory cytokines or other unknown factors.

Some of the causes or associations of NASH are as follows:

* Obesity
* Diabetes
* Hyperlipidemia (increased serum Triglycerides)
* Hypo Thyroidism
* Certain drugs
* Protein-calorie malnutrition
* Starvation or rapid weight loss
* Total parenteral nutrition
* Jejunoileal bypass
* In many cases, no discernible cause is present.

What are the signs and symptoms of NAFLD and NASH and how is it diagnosed?

Many individuals with Non-Alcoholic Fatty Liver Disease (NAFLD) may have no symptoms or may experience vague abdominal discomfort. The problem may come to light during:

A routine physical examination in which the liver is detected to be enlarged.


Routine blood tests in which the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are found to be elevated.


An ultrasound examination may reveal a liver enlarged due to infiltration with fat.


Evaluation for mild symptoms like upper abdominal pain or heaviness, fatigue or dysepepsia.
The diagnosis of NASH is confirmed by liver biopsy. The histological features of the condition include macro vesicular fatty changes; parenchymal inflammation, fibrosis; and presence of Mallory hyaline bodies; cirrhosis in the late stages. The pathogenesis of NASH is unclear, but various theories have implicated free fatty acids. Although NASH is generally considered to be a benign disease, it occasionally progresses to cirrhosis with a fatal outcome.
Evaluation by tests
Once suspected to have NAFLD or NASH, the tests usually required include:



Ultrasound examination


Blood glucose levels: fasting and two hours after meals


Serum lipid profile, especially for triglycerides.


Liver function tests: Serum bilirubin (total and direct), aminotransferase (ALT/AST), albumin


Thyroid stimulating hormone (TSH)


Liver biopsy: if ALT/AST are elevated above normal (this may be an individualized decision in consultation with your gastroenterologist/hepatologist)


Tests to exclude other causes of liver disease also may be done.
What harm will it cause?

Fatty liver in most patients may not cause harm. But in some it may progress slowly over a period of 8-10 years to cirrhosis of the liver (shrunken liver). Cirrhosis is an irreversible stage and its consequences can be life threatening like blood vomits, abdominal distension with fluid, or coma. To identify those who progress to cirrhosis additional tests like liver biopsy is helpful.

Association with other diseases

NAFLD is often associated with obesity (specially the central type), diabetes mellitus, Hyperlipidemia and coronary artery disease in what is referred to as Syndrome X.

Histological findings for NASH

The diagnosis of fatty liver or NASH can be established only with a liver biopsy. Specific histological findings include:
* steatosis or presence of large droplets of fat within liver cells.
* Which usually is macro vesicular but may be micro vesicular or mixed
* inflammation that is mixed neutrophilic and mononuclear cell, portal infiltrates usually are not seen (unlike in hepatitis C)
* Mallory bodies and glycogen nuclei.
* Fibrosis or cirrhosis may be present in advanced cases.

Evaluation by test Once suspected to have NAFLD or NASH, the tests usually required include:

Ultrasound examination
Blood glucose levels: fasting and two hours after meals
Serum lipid profile, specially for triglycerides
Liver function tests: Serum bilirubin (total and direct), aminotransferase (ALT/AST), albumin
Thyroid stimulating hormone (TSH)
Liver biopsy: if ALT/AST are elevated above normal
Tests to exclude other causes of liver disease

What medical care is required?

Abstinence from alcohol may reverse steatosis in patients with alcohol-related fatty liver. Several treatment strategies have been suggested for NAFLD, which are:

Weight loss in obese patients is achieved essentially in two ways:
1. Dieting
2. Exercise

Dieting

Many people believe that to lose weight they have to go on a low-calorie diet, which according to them often means starving oneself until the diet is no longer tolerable. However, this is an incorrect approach. Weight loss should be gradual as loosing weight abruptly has been associated with progression of the disease. The first thing to realize is that changing eating habits must be more than a short-term means to an end. Changing eating habits is the cornerstone of permanent weight control. There is no way to "lose 10 kgs in two weeks" and make it last. Very-low-calorie diets cause major problems; they lower one's metabolic rate, making it harder to lose weight. The best weight control program is a high-complex-carbohydrate, low-fat, vegetarian diet complemented by regular aerobic exercise to boost up the basal metabolic rate. This is the best choice for a healthier, longer, happier life.

Calorie Chart

Some of the common food stuffs, which give 80 calories when consumed, are:
Roti (6 inches diameter)- 1
Rice 1 katori (small)
Bread 1 slice
Dals- Arhar, Mung, Urad, Chana-3/4 katori
Rajma-1/2 katori
Mutton 3 pieces
Chicken- 1 piece (breast piece)
Egg- 1
Milk (buffalo)- 1/2 cup
Milk (toned)- 1 cup
Curd- 1 cup

Fruits, which give 40 calories, are:

Apple- 1 (small)
Banana- 1 (small)
Grapes- 20
Mango- 1/2 (small)
Pineapple- 1/2 cup
Watermelon- 1 cup
Orange- 1
Guava- 2 (small)



Points to remember

1. Use low fat or no fat salad dressings. Regular dressings may have more than 10 grams of fat in one tablespoon.
2. Eat a variety of foods. Your body needs more than 40 different nutrients to stay healthy.
3. Balance the amount you eat with your activity level.

4. Steam, stir-fry or microwave vegetables. For great taste and just a few calories, spice them up with herbs, spices, lemon juice or vinegar.

5. Cutting the fat in meats is easy. Trim off as much fat as possible and remove the skin from poultry. Eat a 3-4 ounce portion, the recommended serving size, which is the size of a deck of cards.

6. Look for the words, 'Whole Wheat' or '100% Whole Wheat' on breads to get more nutrients and fiber.

7. Dried fruit, such as raisins, prunes, apricots, or apples make a great low calorie snack in the car or when you are on the go.

8. Keep healthy, crunchy foods available. Try baby carrots, fresh apples, breakfast cereals.

9. Chose skim or no fat milk. Avoid shakes like mango-shake, banana-shake and chocolate-shake, etc.

10. Stick with broth or tomato based soups to cut the fat. Cream based soups are often made with cream or whole milk that increases the fat and calorie content considerably.

11. Do not consume alcohol. It adds to the already existing liver damage.

12. Avoid fatty foods like ghee, butter and pizzas etc. as they contain saturated fats.

13. Do not take unnecessary drugs without the advice of your physician. Most of the drugs cause damage to the liver.

14. Consume large quantities of vegetables and salads like green leafy vegetables, fruits etc. They contain substances called anti-oxidants, which protect liver from damage.

15. Eat slowly! It gives your brain a chance to send the 'I am full' signal to your stomach before you overeat.

16. Resign from the 'clean plate' club. If you have had enough, leave food on your plate. Your waistline will be glad you did.
17. Learn to compensate! If you eat too many high fat foods one day or just eat too much, consider cutting back the next day.

Exercise

The key to losing weight is to use more calories than you consume. To lose 1 kg you must burn 7000 calories. The most effective way to do this is by combining both diet and exercise. Exercise regularly to loose weight. The daily work that you do is not exercise. Moreover, physical exercise can improve both your mental and physical health. Exercises can be broadly classified as:

Aerobic exercise

Aerobic exercise promotes cardiovascular fitness by raising your pulse to a targeted level and must be undertaken for atleast 30 minutes, three times a week. This strengthens your heart, and as the heart pumps more blood, prevents the build-up of fatty deposits and blood clots. Aerobic exercise also strengthens your lungs, helps control weight, and increases muscle and joint flexibility making you less susceptible to injury. Some examples of aerobic exercise are jogging, bicycling, swimming, brisk walking and aerobic dance.
An effective exercise program should include:



Warm-up - 5 minutes

A warm-up gradually increases your heart rate and the blood flow to the heart and muscles preparing them for exercise it also loosens the joints and relieves muscle spasm, thereby helping to avoid sprains. To warm-up, extremely obese patients can start by walking at a slow pace for about 5 minutes.

Aerobic Activity - 5 to 10 minutes at first, gradually increasing to 45 minutes

The term aerobic means, "using oxygen." During aerobic exercise you use oxygen to burn fat for energy. With the passage of time, gradually increase the time-span and pace of the aerobic exercise you prefer.

Cool-down - 5 minutes

Cooling down allows your heart rate, breathing and blood pressure to return to normal. It also prevents blood from pooling in your working muscles, returns it to your heart and brain, and prepares your body for stretching. To cool down, decrease your activity to

Stretching - 5 to 10 minutes

Stretching will improve your flexibility, decrease muscle soreness and help you relax. Stretch your major muscle groups, the muscles you were using for your exercise. Stretch in a relaxed, controlled manner. Hold each stretch for 20-30 seconds. Do not bounce. Your stretching should last for 5-10 minutes.

Anaerobic exercise

Anaerobic exercise promotes specific muscle size, endurance and strength. Weight lifting and using muscles against resistance (spring etc.) are examples of anaerobic exercises. This form of exercise will not provide as many benefits but is a good supplement to your aerobic workout.
Remember, there are many benefits from exercise. You will sleep better, be more alert, handle stress better and you will even look and feel better. Choose an exercise program that fits your particular needs. Weight loss in individuals who are obese may result in improvement in laboratory abnormalities, shistological findings (steatosis), and CT attenuation. The improvement usually is realized within the first 14 kgs of weight loss.

What are the benefits one can accrue from a regular exercise plan?

Remember, there are many benefits from exercise. It helps your cardiovascular system including your heart, it helps lungs, decreases weight, decreases insulin resistance, and decreases the fat all over body including that deposited in the liver.You will sleep better, be more alert, handle stress better and you will even look and feel better. Choose an exercise program that fits your particular needs. Weight loss in individuals who are obese may result in improvement in laboratory abnormalities, and histological and radiological findings (steatosis). The improvement usually is realized within the first 14 kgs of weight loss.

SOURCE:

http://www.gastroindia.in/nonalcoholicsteatohepatitis.html